Siddharth Agrawal

Transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens in aphakic nonvitrectomized eyes

Purpose: To evaluate the outcome of transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens (PCIOL) in aphakia in nonvitrectomized eyes. Materials and Methods: Patients with postcataract surgery aphakia, trauma with posterior capsule injury, subluxated crystalline lens, and per operative complications where sulcus implantation was not possible were included over a 1-year period. Scleral fixation of acrylic hydrophilic PCIOL was performed according to the described technique, and the patients were evaluated on the day 1, 3, 14, and at 3 and 12 months postoperatively for IOL centration, pseudophakodonesis, change in best-corrected visual acuity (BCVA), and any other complications. Results: Out of twenty-nine eyes of 24 patients, who completed the study, 25 (86.2%) eyes had improved, 2 (6.9%) eyes showed no change, and 2 (6.9%) eyes had worsening of BCVA. Three (10.3%) eyes developed postoperative complications. A significant improvement in mean BCVA (P < 0.0001) was observed after the procedure. Mean duration of follow-up was 26.2 months (range 22–35 months). Conclusion: The use of closed loop haptic acrylic IOL for scleral fixation appears to be safe and effective alternative to conventional scleral fixated polymethyl methacrylate intraocular lenses.

Outcome of Unilateral Inferior Oblique Recession

PURPOSE The aim of this study was to analyze the outcome of unilateral inferior oblique (IO) recession in patients with unilateral or asymmetrical IO overaction in terms of effectiveness, stability, and undesired effects. METHODS Fifteen patients with nonparalytic strabismus who underwent unilateral IO recession for unilateral or asymmetric IO overaction and horizontal muscle surgery were included in this study. Nine patients demonstrated asymmetric bilateral IO overaction, whereas 6 had unilateral overaction. All patients underwent IO recession to the Scheie Parks point in one eye, along with conventional horizontal muscle surgery. Clinical outcome assessment included changes in oblique muscle dysfunction in both eyes. Changes in horizontal deviation, V pattern, vertical deviation, and excyclotorsion were also studied. RESULTS Satisfactory outcome in terms of oblique muscle function, V pattern, vertical deviation, and cyclodeviation was achieved in all patients with unilateral IO overaction and 7 (77%) patients with bilateral IO overaction. Increased IO overaction in the other eye was noted in 2 patients. Satisfactory outcome in patients with bilateral overaction was related to degree of asymmetry in IO overaction between the 2 eyes. CONCLUSION Unilateral IO recession is effective in patients with unilateral IO overaction and selected patients with largely asymmetrical bilateral IO overaction.

Cross-sectional study of macular thickness variations in unilateral amblyopia

Aim: The aim of this study is to compare the mean macular thickness between normal and amblyopic eyes in unilateral strabismic and anisometropic amblyopia. Materials and Methods: A spectral domain-optical coherence tomography (Carl Zeiss Meditech, Inc.) was used to evaluate 51 patients (mean age 11.63 ± 2.84 years) with unilateral strabismic ( n = 29) and anisometropic ( n = 22) amblyopia. Data between the two eyes were compared using a paired t -test and a P value Results: Mean best-corrected visual acuity was +0.53 LogMAR (range 0.2-1.0) in the amblyopic eye. Mean macular thickness in the amblyopic eyes was 277.5 μ ± 15.3 and in the fellow normal eyes was 272.4 μ ± 13.1 ( P P = 0.01) and not significant in anisometropic amblyopia ( P = 0.08). Conclusion: The mean macular thickness was greater in amblyopic eyes as compared to the normal fellow eyes, and this difference was significant in strabismic amblyopia, but not significant in anisometric amblyopia.

Evaluating a new surgical dosage calculation method for esotropia.

Purpose: To evaluate a simplified method for correction of ocular deviation in patients of infantile and acquired basic esotropia. Materials and Methods: Thirty-six consecutive patients of infantile and acquired basic esotropia were selected for this study. Patients underwent unilateral recession–resection surgery as per the new norm gram. Patients underwent 3.5-7 mm recession of medial rectus (MR) in one eye depending on the pre-operative deviation and patients age. Together they also underwent 6 or 7 mm resection of the lateral rectus (LR) in the same eye depending on patients age (6 mm for 3 years and below and 7 mm for older age). In patients 3 years and below, a correction of 6, 7, or 8 PD/mm of recession of MR was expected when the pre-operative deviation was lesser than 30 PD, between 30 and 60 PD, or above 60 PD, respectively. Similarly, these values were 5, 6, and 7 PD/mm of MR recession in patients above 3 years. A ratio between achieved and expected correction was calculated and the calculation was deemed successful for a patient if this ratio fell between 0.9 and 1.1. Methods: Thirty-six consecutive patients of infantile and acquired basic esotropia were selected for this study. Patients underwent unilateral recession-resection surgery as per the new norm gram. Patients underwent 3.5-7 mm recession of medial rectus (MR) in one eye depending on the pre-operative deviation and patients age. Together they also underwent 6 or 7 mm resection of the lateral rectus (LR) in the same eye depending on patients age (6 mm for 3 years and below and 7 mm for older age). In patients 3 years and below, a correction of 6, 7, or 8 PD/mm of recession of MR was expected when the pre-operative deviation was lesser than 30 PD, between 30 and 60 PD, or above 60 PD, respectively. Similarly, these values were 5, 6, and 7 PD/mm of MR recession in patients above 3 years. A ratio between achieved and expected correction was calculated and the calculation was deemed successful for a patient if this ratio fell between 0.9 and 1.1. Results: The calculation procedure was successful in 33 out of 36 patients (91%). The two-tailed probability on paired Wilcoxon test was 0.187. Conclusions: This simplified method of surgical dosage calculation using MR recession as basis is predictable in patients of infantile and basic Esotropia. It may serve as a useful tool for minimizing variability of surgical results.

Correlation of visual functions with macular thickness in primary open angle glaucoma

Aim: The aim of this study was to establish a correlation between macular thickness on optical coherence tomography (OCT) and 2 visual functions (visual acuity and contrast sensitivity [CS]) in established cases of primary open angle glaucoma (POAG). Materials and Methods: A total of 50 consecutive patients of established POAG between 40 years and 70 years of age attending the glaucoma clinic of a tertiary care eye center in North India were enrolled for this cross-sectional study. Best corrected visual acuity (BCVA), CS and macular thickness by spectral-domain-OCT (Cirrus HD-OCT, CarlZeiss, Germany) were evaluated. Statistical Analysis: The groups were compared together by one factor analysis of variance and the significance of mean difference between the groups was done by Newman-Keuls test. Results: Newman-Keuls test revealed a direct relationship of macular thickness to BCVA and CS (P < 0.05). Conclusion: BCVA and CS are directly related to the macular thickness on OCT.

A novel technique to recanalize the nasolacrimal duct with endodiathermy bipolar probe

Aims: To evaluate a new approach for recanalization (RC) of nasolacrimal duct obstruction in the treatment of the symptomatic nasolacrimal duct obstruction (NLDO). Materials and Methods: A prospective, interventional, comparative study in 302 eyes of 209 patients of symptomatic nontraumatic NLDO. Eyes with previous failed surgery were excluded. One hundred and fifty-one eyes underwent RC with 20 G endodiathermy bipolar probe connected to a 7 W diathermy followed by bicanalicular intubation under direct visualization. One hundred and fifty-one eyes underwent standard external dacryocystorhinostomy (DCR). Follow-up was for 24 months and evaluation was done on basis of change in symptoms and lacrimal syringing. Data was analyzed by Chi-square test and unpaired t-test. P value < 0.05 was considered statistically significant. Results: Success defined as an asymptomatic patient or freely patent syringing was 92.7% (140 eyes) in RC group and 83.44% (126 eyes) in DCR group. Success was significantly more (P ≤ 0.01) in RC than DCR group. Surgical time was significantly less in RC than DCR (P ≤ 0.001). In RC group, RC could not be performed in three eyes and had to be later taken up for DCR. Intubation after RC was not achieved in four eyes; however these eyes had a patent pathway till 24 months. Twenty-two eyes had a premature extrusion of the tube; but the success rate in these (20 eyes) was comparable to the others within the group (P > 0.05). Two eyes in RC and one in DCR group had complications. Conclusions: RC with 20 G endodiathermy bipolar probe is a quick, simple, and effective alternative to standard external DCR.

Topical Anesthesia in High Volume Cataract Surgery: Pain Evaluation andFeasibility Study

Context: This study was undertaken to evaluate the use of topical anesthesia for Manual small incision cataract surgery in high volume cataract surgery setup. Aims: The primary aim was to evaluate the pain experience of the patients undergoing Manual Small Incision Cataract Surgery (MSICS) under topical anesthesia using 2% lignocaine jelly in high volume cataract surgery setup. Secondary aims were to study any relation between the pain experience and education status, gender and age of the patients. Settings and Design: The study was an Interventional case series conducted at a tertiary care eye hospital. Methods and Material: Patients screened at the peripheral field camps were transported to base hospital and underwent MSICS under topical anesthesia using lignocaine 2% jelly and intracameral 0.5% lignocaine solution. Demographic data and pain experience of the patients during the surgery was recorded and analyzed. Statistical analysis: Statistical analysis was done using MedCalc® version 12.2.1.0 software for Windows 7. Descriptive analysis, Mann-Whitney test, Kruskal-Wallis test, and Spearman’s rho coefficient were used to analyze the data. Results: The study included 270 patients, with average age 62.7 years. Average pain score was 1.6 units (SD ± 0.72, scale 1-5) with ~85% patients reporting comfortable experience. Pain perception had no relation to gender, education status or age. Conclusions: Manual Small Incision Cataract Surgery under topical anesthesia using lignocaine 2% jelly and intracameral lignocaine, in high volume cataract surgeries safe and comfortable to majority of patients and is unaffected by gender, age or educational status of the patients.

Query to the author of retinoblastoma: Achieving new standards with methods of chemotherapy

Dear Sir, We have read the symposium article titled “Retinoblastoma: Achieving new standards with methods of chemotherapy” by Kaliki and Shields [1] with great interest and appreciate their effort to summate the present status of chemotherapy for retinoblastoma. We noticed that the Fig. 2 depicted in the article on page number 105 of the journal, claims that the systemic chemotherapy reduces the size of orbital retinoblastoma as per the attached legend “Treatment of the orbital retinoblastoma with intravenous chemotherapy (a) Orbital retinoblastoma of the left eye confirmed on (b) computed tomography scan of the orbit. (c and d) Nine cycles of high-dose chemotherapy resulted in phthisis bulbi facilitating enucleation. No residual tumor was noted on histopathology. The patient subsequently underwent left orbit external beam radiotherapy and further three cycles of high-dose chemotherapy.” The figure depicts the change in retinoblastoma tumor of single patient over a period of time after systemic chemotherapy. However, it is obvious that the images depicted are of two separate patients and the one labeled (a) with advanced tumor is of a patient with older age, darker iris, and a mole on the left slope of the nasal bridge. The image (c) of Fig. 2 is a different patient with lighter iris and no mole at the mentioned site. We would like to thank the authors for explaining the anomaly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Adjustable recessions in horizontal comitant strabismus: A pilot study

Aim: To compare the surgical outcome of adjustable with the conventional recession in patients with horizontal comitant strabismus. Patients and Methods: A prospective comparative nonrandomized interventional pilot study was performed on patients with horizontal comitant strabismus. Fifty-four patients (27 in each group) were allocated into 2 groups to undergo either adjustable suture (AS) recession or non-AS (NAS) recession along with conventional resection. The patients were followed up for 6 months. A successful outcome was defined as deviation ±10 prism diopters at 6 months. The results were statistically analyzed by Chi-square test, Fishers exact test, and Students t-test. Results: A successful outcome was found in 24 (88.8%) patients in AS and 17 (62.9%) in NAS group (P = 0.02). The postoperative adjustment was done in 13 (48.1%) patients in AS group. There was one complication (tenons cyst) in AS group. Conclusion: AS recession may be considered in all cooperative patients undergoing strabismus surgery for comitant deviations.

Corrrection of exotropia by implantable collamer lens

Sir, Exotropia associated with myopia is a common presentation in strabismus practice. Usually, the deviation is corrected by appropriate refractive correction.[1] However, patients presenting late, having high myopia or significant anisometropia, have limited binocularity and the deviation remains unchanged with use of glasses.[1] Refractive correction by phakic intraocular lenses (IOLs) has been known to significantly improve the quality of vision, enhance binocular functions, and also has a positive impact on ocular deviations.[2,3] A 21-year-old lady presented in our strabismus clinic for cosmetic correction. She was using a refractive correction of −4.5 D sphere in right eye (RE) and plain glass in left eye (LE) for 2 years. Her logMAR visual acuity (VA) with glasses was 0.0 (20/20) RE and 1.5 (20/640) LE. She had left ET of 25PD with no variability or incomitance. Her correction was appropriate in RE; however, but LE improved to 1.1 (20/250) with −20.0 D Sphere. Both eyes had myopic degeneration with no staphyloma or treatable lesions. RE amblyopia therapy trial for 3 months caused no change in VA or ocular deviation. Simultaneous macular perception without fusion was present. Refractive correction followed by ocular alignment was planned. After appropriate evaluation and peripheral iridotomies, the patient underwent implantable collamer lens (Visian Implantable collamer lens (ICL) − Staar Surgical, California) implantation simultaneously in both eyes (−6.5 D RE, −23.0 D LE). 3 days postoperatively, the uncorrected VA improved to −0.1 (20/16) in the RE. The corrected VA in LE was 0.6 (20/80) with −0.75 D Sph. She was orthophoric for distance and near with fusion with a limited range. The following factors played a role in satisfactory outcome of our patient: Contact lenses are known to increase the accommodative effort in myopes compared to spectacles with the increase being proportional to the refractive error.[4] The phakic IOLs have a greater effect on the accommodative effort.[2,3] An exotrope, when wearing minus spectacle lenses, looks through a base out prism which apparently increases the magnitude of an exodeviation. The prismatic effect is proportional to the refractive correction. When contact lenses (or phakic IOLs) are used, this effect is eliminated, revealing the true angle of deviation.[5] A large portion of the stimulus to fuse is elicited through the peripheral field of vision. For highly myopic patients, glasses create significant peripheral distortion. With phakic IOLs, peripheral distortions are eliminated making fusion easier.[6] A clearer, lesser minified, and aniseiokonic image stimulates and enhances binocularity. Myopic refractive correction closer to the nodal point is well-known to improve VA.[7] The observations of (i) restoration of ocular alignment, (ii) elimination of need for spectacles, (iii) improvement in best corrected VA, and (iv) improvement in binocularity prove the optical and functional superiority of ICL over spectacle lenses. But for the ICL, this patient may have been subjected to strabismus surgery. This demonstrates that patients with ocular deviations associated with high refractive errors should undergo an appropriate procedure to eliminate spectacles before squint surgery.